Purpose: The role and benefit of concomitant tricuspid valve repair (TVR) during ventricular assist device (VAD) implant remains unclear. Previously published data utilized historical VADs. Outcomes of TVR with contemporary LVAD implant remain unknown. We aimed to analyze our center's outcomes in a modern cohort with a focus on the role of TVR in mitigating RV dysfunction and improving LV unloading post LVAD.

Purpose: Optimal outcomes in left ventricular assist device (LVAD) therapy recipients require adequate right ventricular (RV) function. However, predicting RV failure remains challenging in many cases, and occasionally, the RV must be supported with mechanical support. RV assist device (RVAD) use adds excess morbidity and mortality. Therefore, strategies to avoid RVAD use in LVAD patients are necessary for optimal outcomes. We have focused on 1) reducing transfusions, 2) tricuspid valve repair, 3) keep mean arterial pressure > 70 mmHg, 4) optimizing pump speed to balance the ventricular septum, 5) inotrope use.

Introduction: Approximately 75% of women that undergo coronary angiography for angina do not have obstructive disease. However, a significant number have persistent angina, which can reduce their functional capacity and performance, impacting patients’ quality of life. There is a need for further studies that accurately compare angina and functional capacity among women angina with non-obstructive coronary disease (ANOCA). Objective: We examined the association between perceived anginal symptoms and functional capacity in patients with ANOCA Methods: A the Women’s Heart Center at the Christ Hospital, all women completed the Duke Activity Status Index (DASI) and Seattle Angina Questionnaire-7 (SAQ7) at the initial visit. DASI score range from 0 to 58.2 and assess functional capacity using self-assessment and VO2 peak formula with higher scores indicating better functional capacity. SAQ7 assesses angina symptoms, physical limitation, and quality of life; the score is from 0-100, where a lower score indicates a higher frequency of angina, increased physical limitation, and poor quality of life. DASI and SAQ7 scores were correlated. Sperman correlation and Mcnemar chi-square were used to compare DASI and SAQ7 score results. Results: Among 225 women with ANOCA, the mean DASI score was 16.73, and the mean SAQ7 score was 43.79. 63.1% reported a low score of SAQ7, and 79.6% reported a low DASI score. SAQ7 and DASI were moderately correlated (Spearman correlation of +0.42). Further analysis with McNemar chi- square showed that women with lower SAQ7 (score 0-49.4) tends to corresponds with low DASI (score 0-24.5) (Specificity 86.6%), compared to women with higher SAQ7 (score 49.5-100) and high DASI (score 24.6-58.2) (Sensitivity 32.5%) (p<0.001). Discussion: Anginal symptoms are correlated with reduced functional capacity among women with ANOCA. Further prospective studies are needed to evaluate the correlation between angina improvement and functional capacity.

Background and Objectives: Moderate aortic stenosis (AS) confers a surprisingly adverse prognosis, approaching that of severe AS. The objective of this study was to describe the clinical course of patients with moderate AS with evidence of concomitant heart failure manifesting as elevated brain natriuretic peptide (BNP) levels. Methods: This is a single-center, retrospective cohort study of 332 patients with elevated BNP. 165 patients with moderate AS were compared with 167 controls with none-mild AS. The Median follow-up duration was 3.85 years. The primary outcome was a composite endpoint of all-cause hospitalizations and all-cause mortality. Results: BNP levels were 530 and 515 pg/mL in the study and the control groups, respectively. Moderate AS had significantly higher rates of primary composite endpoint in both univariate analysis (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.14-1.97; p=0.004) and adjusted analysis (HR, 1.45; 95% CI, 1.05-2.01; p=0.02). Moderate AS had 1.41 (95% CI, 1.18- 1.69; p<0.001) times more all-cause hospitalization per patient-year of follow-up compared to controls in the univariate model. After adjustment for significant covariates, moderate AS remained an independent predictor of all-cause hospitalizations (incidence rate ratio [IRR], 1.45; 95% CI, 1.18-1.79; p=0.005). Furthermore, moderate AS was significantly associated with higher all-cause hospitalization rates in both heart failure with reduced ejection fraction (IRR, 1.33; 95% CI, 1.02-1.75; p=0.038) and heart failure with preserved ejection fraction [IRR], 1.31; 95% CI, 1.03-1.67; p=0.026).Conclusions: Moderate AS in conjunction with elevated BNP portends a significantly worse prognosis than those without moderate AS and should be followed closely.

Background: We report 10-year follow up data from a well-established Resistant Hypertension Program. Methods and Results: Between January 2012 and December 2021, there were 976 referrals, of which 357 were excluded, due to non-adherence/no-show. Therefore, demographic and clinical data from 619 patients are summarized in Table 1. Average duration of enrollment was 8.1 months with an average of 4.3 visits. The baseline and final data are shown in Table 2. Despite no weight loss, there were significant reductions in systolic BP (150.2 to 129.5 mmHg, p< 0.05) and diastolic BP (84.8 to 76.3 mmHg, p< 0.05). Average number of antihypertensive medications increased from 1.7 to 3.4, p< 0.05). There data are very similar to those from the first year of the program. Conclusions: Ten-year data from a well-established Resistant Hypertension Program maintained significant blood pressure reductions, similar to results from the first year of program.

This study tested the hypothesis that continuous bilateral erector spinae plane blocks placed preoperatively would reduce opioid consumption and improve outcomes compared with standard practice in open cardiac surgery patients. Patients who received bilateral continuous erector spinae plane blocks for primary open coronary bypass, aortic valve, or ascending aortic surgery were compared to a historical control group. Patients in the block group received a 0.5% ropivacaine bolus preoperatively followed by a 0.2% ropivacaine infusion begun postoperatively. No other changes were made to the perioperative care protocol. The primary outcome was opioid consumption. Secondary outcomes were time to extubation and length of stay. Twenty-eight patients received continuous erector spinae plane blocks and fifty patients served as historic controls. Patients who received blocks consumed less opioids, expressed as oral morphine equivalents, both intraoperatively (34 ± 17 vs. 224 ± 125 mg) and during their hospitalization (224 ± 108 vs. 461 ± 185 mg). Patients who received blocks had shorter times to extubation (126 ± 87 vs. 257 ± 188 min) and lengths of stay in the intensive care unit (35 ± 17 vs. 58 ± 42 h) and hospital (5.6 ± 1.6 vs. 7.7 ± 4.6 days). Continuous erector spinae plane blocks placed prior to open cardiac surgical procedures reduced opioid consumption, time to extubation, and length of stay compared to a standard perioperative pathway.

BACKGROUND:Rapid Diagnostic Testing (RDT), a point-of-care, qualitative test for Plasmodium antigen, has been a catalyst in the diagnosis of patients in malaria-endemic regions. While blood-smear microscopy remains the gold standard, RDT allows for swift diagnosis in resource-poor settings. Our study sought to utilize RDT to quantify local malaria prevalence in the Rorya district of Tanzania.MATERIALS AND METHODS:Two field clinics were established and 1,032 patients were screened. Those that described malaria symptoms were tested via RDT. The percentage of positive tests was compared to national data from the World Health Organization's 2019 World Malaria report and the President's Malaria Initiative Report for Tanzania. Intake data (sex, age, heart rate (HR), and temperature) were compared between the malaria-positive and malaria-negative groups.RESULTS:772 patients received RDT of whom 487 tested positive. There was a statistically significant difference in the percentage of positive patients between the two sites (52.0% vs 38.2%). Sixty percent of malaria-positives were female and the median age of this group was 10 yrs (range 5-15 yrs). Intake data showed a notable difference in median heart rates between malaria-positive and malaria-negative persons, 84.0 (72-100) and 72.0 (74-84) beats per minute (bpm), respectively.CONCLUSIONS:The prevalence of malaria in Rorya was significantly higher than the reported Tanzanian average. Additionally, children were at a statistically higher risk of contracting malaria. Our data indicates that RDT offers enhanced insight into the local malarial burden that may be valuable to (governmental) health providers for the disbursement of resources in malaria-endemic regions.

Background: The aim of this study was to examine the relationship between baseline left ventricular (LV) geometry and outcomes after transcatheter aortic valve replacement (TAVR). Methods: Patients undergoing TAVR (n = 206) had baseline LV geometry classified as (1) concentric hypertrophy, (2) eccentric hypertrophy, (3) concentric remodeling, or (4) normal. Descriptive statistics, Kaplan-Meier time-to-event analysis, and Cox regression were performed. Results: Distribution of baseline LV geometry differed between male and female patients (chi(2) = 16.83, P = .001) but not at 1 month (chi(2) = 2.56, P = .47) or 1 year (chi(2) = 5.68, P = .13). After TAVR, a majority of patients with concentric hypertrophy evolved to concentric remodeling. Survival differed across LV geometry groups at 1 year (chi(2)[3] = 8.108, P = .044, log-rank test) and at 6.5 years (chi(2)[3] = 9.023, P = .029, log-rank test). Compared with patients with concentric hypertrophy, patients with normal geometry (hazard ratio, 2.25; 95% CI, 1.12-4.54; P = .023) and concentric remodeling (hazard ratio, 1.89; 95% CI, 1.12-3.17; P = .016) had higher rates of all-cause mortality. Conclusions: Baseline concentric hypertrophy confers a survival advantage after TAVR. Although baseline patterns of LV geometry appear gender specific (with women demonstrating more concentric hypertrophy), this difference resolves after TAVR.

Objective Minimally invasive cardiac surgery via a right minithoracotomy (RMT) is a common approach to different valve pathologies, tumor resection, and atrial septal defect (ASD) closure. We studied intraoperative field block using liposomal bupivacaine (LB) in these operations. Methods Consecutive 171 minimally invasive RMTs (fourth intercostal space) were studied, and patients in cardiogenic or septic shock, intravenous drug abuse, and those re-explored were excluded (n = 12). An early cohort was treated with standard postoperative analgesia while another underwent intraoperative field block with LB immediately after incision. We compared postoperative pain level, narcotic utilization (morphine milligram equivalent), and intensive care unit (ICU) and hospital length of stay. Results The procedures included 48 isolated mitral valve replacements (MVR); 2 MVR with other procedures; 93 mitral valve repairs (MVRr); 9 MVRr with other procedures; 4 isolated tricuspid valve repairs; 2 myxoma resections; 1 ASD closure. There were 13 patients in the non-LB group and 146 patients in the LB group. Use of LB decreased mean postoperative narcotic utilization by 50% (P = 0.003). The LB group had lower pain levels on postoperative day 1 (P = 0.039), which continued through postoperative day 5 (P = 0.030). We found no difference in ICU or hospital length of stay between groups. There were no complications from LB field block. Conclusions LB field block decreases postoperative pain and narcotic utilization after cardiac surgery via a RMT, but it does not reduce length of stay. The technique is safe and should be considered in all patients undergoing RMT cardiac surgery.

INTRODUCTION:Aortic stenosis (AS) imposes a significant afterload on the left ventricle, but regional manifestations of the overall load may not be uniform, leading to mechanical dyssynchrony. Accordingly, we evaluated the prevalence of dyssynchrony in patients with severe AS at baseline as well as changes after transfemoral aortic valve replacement (TAVR). METHODS:This study is a retrospective analysis of 225 patients in sinus rhythm who underwent TAVR for severe AS, in whom inter-ventricular and intra-ventricular dyssynchrony were measured at baseline, discharge, 1 month, and 1 year. Inter-ventricular dyssynchrony was defined as the difference between left and right ventricular pre-ejection intervals; intra-ventricular dyssynchrony was defined as the difference between time to peak systolic velocity of the basal septal and lateral segments. Patients were further stratified into those with QRS <120 ms or >120 ms. RESULTS:At baseline, a quarter of patients met the criterion for significant inter-ventricular dyssynchrony, and a third had evidence of intra-ventricular dyssynchrony. Both decreased after TAVR although only the intra-ventricular dyssynchrony reached statistical significance. The interplay between QRS duration and changes in inter- and intra-ventricular dyssynchrony are also explored. CONCLUSIONS:In patients with severe AS, there was evidence of mechanical dyssynchrony that is improved post-TAVR. Whether dyssynchrony is clinically and prognostically significant, and if it represents a potential target for additional therapy remains to be studied.

Transcatheter aortic valve replacement (TAVR) has become the primary method of aortic valve replacement for intermediatea and high surgical risk patients with aortic stenosis (AS). While prior data support a general rise in EF after TAVR, the relationship between baseline EF and change after TAVR

PURPOSE:To investigate right ventricular (RV) strain in patients without identified cardiac pathology using cardiac magnetic resonance tissue tracking (CMR TT). METHODS:A total of 50 consecutive patients with no identified cardiac pathology were analyzed. RV longitudinal and circumferential strain was assessed by CMR TT. The age range was 4-81years with a median of 32years (interquartile range, 15 to 56years). RESULTS:Analysis time per patient was <5min. The peak longitudinal strain (Ell) was -22.11±3.51%. The peak circumferential strains (Ecc) for global, basal, mid-cavity and apical segments were as follows: -11.69±2.25%, -11.00±2.45%, -11.17±3.36%, -12.90±3.34%. There were significant gender differences in peak Ecc at the base (P=0.04) and the mid-cavity (P=0.03) with greater deformation in females than in males. On Bland-Altman analysis, peak Ell (mean bias, 0.22±1.67; 95% CI -3.05 to 3.49) and mid-cavity Ecc (mean bias, 0.036±1.75; 95% CI, -3.39 to 3.47) had the best intra-observer agreement and inter-observer agreement, respectively. CONCLUSIONS:RV longitudinal and circumferential strains can be quickly assessed with good intra-observer and inter-observer variability using TT.

Background: Hypertension is associated with alterations of left ventricular geometry that can be characterized by a combination of relative wall thickness (RWT = (septal wall thickness + posterior wall thickeness)/ LV end diastolic diameter) and LV mass. The four resulting categories are: normal, concentric hypertrophy (CH), eccentric hypertrophy (EH), and concentric remodeling (CR). This scheme may be relevant with aortic stenosis (AS) patients considering transcatheter aortic valve replacement (TAVR) in terms of prognosis and value of intervention. Changes in LV geometry after TAVR may be helpful in further understanding the heart's response to sudden and minimally invasive removal of severe afterload. Accordingly, we evaluated LV geometry in patients undergoing TAVR with serial echocardiography. Methods: Echocardiography was performed at baseline, 1- month and 1- year post procedure. At each time point, LV geometry was categorized as normal (normal RWT, normal LV mass), CH (increased RWT, high LV mass), EH (normal RWT, high LV mass), or CR (increased RWT, normal LV mass). Results: Similar proportion of patients had normal geometry at 1 year as at baseline. At baseline, the majority of patients had increased LV mass (CH and EH). By one year, significant proportion of these patients had evolved their LV geometry to CR, ie. regression of LV mass with or without further wall thinning. Conclusion: LV geometry in patients with AS can be categorized into one of 4 phenotypes based on RWT and LV mass; at one year post TAVR, changes in LV geometry are highlighted by reduction in LV mass, resulting in more patients with CR. Whether these baseline or change in phenotypes are predictive of outcomes remains to be tested. Furthermore, the CR group at baseline may represent the patients with normal ejection fraction, low gradient, and low stroke volume who are at significant risk of poor outcomesTabled 1Baseline(n = 100)1 Month(n = 109)1 Year(n = 85)Concentric Hypertrophy48(48.0%)30(27.5%)*28(32.9%)Concentric Remodeling24(24.0%)39(35.8%)34(40.0%)*Eccentric Hypertrophy11(11.0%)16(14.7%)6(7.1%)Normal17(17.0%)24(22.0%)17(20.0%) Open table in a new tab

Background Stress cardiac magnetic resonance ( CMR ) has typically involved pharmacologic agents. Treadmill CMR has shown utility in single‐center studies but has not undergone multicenter evaluation. Methods and Results Patients referred for treadmill stress nuclear imaging ( SPECT ) were prospectively enrolled across 4 centers. After rest 99m Tc SPECT , patients underwent resting cine CMR . In‐room stress was then performed using an MR ‐compatible treadmill with continuous 12‐lead electrocardiogram monitoring. At peak stress, 99m Tc was injected, and patients rapidly returned to the MR scanner isocenter for real‐time, free‐breathing stress cine and perfusion imaging. After recovery, cine and rest perfusion followed by late gadolinium enhancement acquisitions concluded CMR imaging. Stress SPECT was then acquired in adjacent nuclear laboratories. A subset of patients not referred for invasive coronary angiography within 2 weeks of stress underwent coronary computed tomography angiography. Angiographic data available in 94 patients showed sensitivity of 79%, specificity of 99% for exercise CMR with positive predictive value of 92% and negative predictive value of 96%. Agreement between treadmill stress CMR and angiography was strong (κ=0.82), and moderate between SPECT and angiography (κ=0.46) and CMR versus SPECT (κ=0.48). Conclusions The multicenter EXACT trial indicates excellent diagnostic value of treadmill stress CMR in typical patients referred for exercise SPECT .

Heart failure (HF) affects 5.1 million adult patients, accounting for over 1 million hospitalizations, 1.8 million office visits, and nearly 680,000 emergency department visits annually. HF hospitalizations have been incorporated into a national measure of hospital and provider quality, with associated financial penalties based on the 30-day readmission rate after an index hospitalization for HF. However, it is not clear whether the number of HF-related hospitalizations or 30-day readmissions is consistently related to quality of care. The relationships between various measures of HF care quality and hospitalization rates were evaluated by performing a cohort study of an HF disease management program in a clinical practice setting. Following the statistical analyses assessing outcomes and survival, the conclusion was that an HF disease management program in clinical practice associated with improved utilization of evidence-based medical and device therapies tends to improve ejection fraction and survival, and reduce sex and race disparities, but not with an associated reduction in hospitalizations or total hospital days.

BackgroundReadmission to the hospital after an index hospitalization for heart failure (HF) is associated with significantly increased risk of adverse outcomes. Furthermore, readmission within 30 days of discharge is a quality measure with major financial implications. Therefore, an easy and reliable method to assess risk of readmission during the index hospitalization would be helpful in managing these patients. Accordingly we developed a tool based on existing data within the electronic health record (EHR, EPIC) at The Christ Hospital, Cincinnati, OH.MethodsA search of the EHR database from January 2008 through December 2011 revealed 3,581 discharges with a primary diagnosis of acute decompensated heart failure, and represented the derivation cohort. The data were analyzed using multivariate logistic regression, and the results were used to develop a prediction tool in order to identify patients' risk of a readmission within 30 days of discharge. Subsequently, an EHR search from Jan 2012 through Dec 2014 revealed 2007 patients who were analyzed similarly, and represented the validation cohort.ResultsThe twelve variables found to be associated with an increased risk of early readmission were hyponatremia, gender, number of documented diagnoses, length of stay, admitting service, estimated income, beta-blocker prescribed upon discharge, loop diuretic prescribed upon discharge, renal dysfunction, chronic obstructive pulmonary disease, cerebrovascular disease, and diabetes mellitus. Of these, admitting service [other than cardiology], hyponatremia, and renal dysfunction were the most predictive of an early hospital readmission, with respective p-values of <0.0001, 0.0001, and 0.0004. A predictive risk scoring system was developed based on this model (very high: 0-0.99, high: 1-1.49, medium 1.5-2.49, low > 2.5). A very high risk group had an observed readmission rate of 29%, whereas the low risk group had a 5.6% observed readmission rate (black line of figure, chi-square p-value=5.0e-11). Similar results were seen in the validation cohort, with the exception of a lower observed readmission in the validation group compared with derivation for the very high risk subgroup. (red line of figure)Conclusion BackgroundReadmission to the hospital after an index hospitalization for heart failure (HF) is associated with significantly increased risk of adverse outcomes. Furthermore, readmission within 30 days of discharge is a quality measure with major financial implications. Therefore, an easy and reliable method to assess risk of readmission during the index hospitalization would be helpful in managing these patients. Accordingly we developed a tool based on existing data within the electronic health record (EHR, EPIC) at The Christ Hospital, Cincinnati, OH. Readmission to the hospital after an index hospitalization for heart failure (HF) is associated with significantly increased risk of adverse outcomes. Furthermore, readmission within 30 days of discharge is a quality measure with major financial implications. Therefore, an easy and reliable method to assess risk of readmission during the index hospitalization would be helpful in managing these patients. Accordingly we developed a tool based on existing data within the electronic health record (EHR, EPIC) at The Christ Hospital, Cincinnati, OH. MethodsA search of the EHR database from January 2008 through December 2011 revealed 3,581 discharges with a primary diagnosis of acute decompensated heart failure, and represented the derivation cohort. The data were analyzed using multivariate logistic regression, and the results were used to develop a prediction tool in order to identify patients' risk of a readmission within 30 days of discharge. Subsequently, an EHR search from Jan 2012 through Dec 2014 revealed 2007 patients who were analyzed similarly, and represented the validation cohort. A search of the EHR database from January 2008 through December 2011 revealed 3,581 discharges with a primary diagnosis of acute decompensated heart failure, and represented the derivation cohort. The data were analyzed using multivariate logistic regression, and the results were used to develop a prediction tool in order to identify patients' risk of a readmission within 30 days of discharge. Subsequently, an EHR search from Jan 2012 through Dec 2014 revealed 2007 patients who were analyzed similarly, and represented the validation cohort. ResultsThe twelve variables found to be associated with an increased risk of early readmission were hyponatremia, gender, number of documented diagnoses, length of stay, admitting service, estimated income, beta-blocker prescribed upon discharge, loop diuretic prescribed upon discharge, renal dysfunction, chronic obstructive pulmonary disease, cerebrovascular disease, and diabetes mellitus. Of these, admitting service [other than cardiology], hyponatremia, and renal dysfunction were the most predictive of an early hospital readmission, with respective p-values of <0.0001, 0.0001, and 0.0004. A predictive risk scoring system was developed based on this model (very high: 0-0.99, high: 1-1.49, medium 1.5-2.49, low > 2.5). A very high risk group had an observed readmission rate of 29%, whereas the low risk group had a 5.6% observed readmission rate (black line of figure, chi-square p-value=5.0e-11). Similar results were seen in the validation cohort, with the exception of a lower observed readmission in the validation group compared with derivation for the very high risk subgroup. (red line of figure) The twelve variables found to be associated with an increased risk of early readmission were hyponatremia, gender, number of documented diagnoses, length of stay, admitting service, estimated income, beta-blocker prescribed upon discharge, loop diuretic prescribed upon discharge, renal dysfunction, chronic obstructive pulmonary disease, cerebrovascular disease, and diabetes mellitus. Of these, admitting service [other than cardiology], hyponatremia, and renal dysfunction were the most predictive of an early hospital readmission, with respective p-values of <0.0001, 0.0001, and 0.0004. A predictive risk scoring system was developed based on this model (very high: 0-0.99, high: 1-1.49, medium 1.5-2.49, low > 2.5). A very high risk group had an observed readmission rate of 29%, whereas the low risk group had a 5.6% observed readmission rate (black line of figure, chi-square p-value=5.0e-11). Similar results were seen in the validation cohort, with the exception of a lower observed readmission in the validation group compared with derivation for the very high risk subgroup. (red line of figure) Conclusion

Background and Objectives In the Ultrafiltration versus Intravenous Diuretics for Patients Hospitalized for Acute Decompensated Heart Failure trial, ultrafiltration (UF) removed volume more effectively than usual care (UC). Hypothetically, UF may be superior to UC due to increased sodium (Na) removal and less neurohormonal activation. We compared UF and UC in a randomized pilot trial of target weight guided therapy for acute decompensated heart failure (ADHF). Subjects and Methods Sixteen patients with ADHF were enrolled and target weights established prospectively, prior to randomization to UC or UF. UF patients did not receive diuretics and UC patients were all treated with a continuous furosemide drip. All urine and ultrafiltrate were collected and Na concentrations measured. Results Similar volumes were removed in UC and UF groups (110105 mL and 107415 mL, respectively) and the UF group also produced 45325 mL of urine. Na concentration was 138±6 meq/L in the ultrafiltrate, 85±73 meq/L in the UC group's urine, and 26±23 meq/L in the UF group's urine. Given the relevant associated volumes, total meq of the Na removed was similar (1168 in UC vs. 1216 in UF). The UF group produced isotonic ultrafiltrate and a higher volume of dilute urine than anticipated. Conclusion In a randomized pilot study of target weight guided therapy with UC or UF for ADHF, there were no differences in total volumes or Na removed, and lengths of hospital stays were similar. Isotonic fluid loss by UF was accompanied by the production of very dilute urine.